- Email: [email protected]
Transgender community voices: a participatory population perspective
Perspectives
Transgender community voices: a participatory population perspective Understanding the global health burden and needs of transgender communities necessitates meaningful engagement and involvement of transgender people. Against the backdrop of widespread social and economic exclusion facing people of diverse gender identities and experiences, community empowerment is essential for clinical services, public health programmes, and human rights efforts that seek to design and implement effective services and population-level interventions to improve the health and wellbeing of transgender people. A participatory population perspective necessitates working with—and not through—local, national, and global transgenderled organisations in the conduct of research and evaluation, delivery
of gender-affirmative clinical care, education and training, and policy and advocacy. From this perspective, we have invited transgender leaders to contribute narratives of their experiences in their local context. These transgender voices bring to life the social contexts, epidemiological data, and identified health-care needs presented across the Lancet Series papers on transgender health; they are especially meant to accompany Sari Reisner and colleagues’ review of the global health burden and needs—a paper on which most of the authors are themselves transgender men and women. The voices narratives are not meant to be, nor could they be, representative of the entire global transgender community given the
heterogeneity of transgender people worldwide. However, these voices are powerful examples of the lived knowledge and personal experiences of transgender people.
Published Online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)00683-8, http://dx.doi.org/10.1016/ S0140-6736(16)00682-6, and http://dx.doi.org/10.1016/ S0140-6736(16)00684-X
*Sari Reisner, JoAnne Keatley, Stefan Baral Division of General Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA (SR); Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA (SR); The Fenway Institute, Fenway Health, Boston, MA, USA (SR); Center of Excellence for Transgender Health, University of California San Francisco, San Francisco, California, USA (JK); and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (SB) [email protected]
Peru: access to health and adverse social context expelled from their homes because of their desire to live differently from their assigned sex. Due to rigid patriarchal norms, transgender women challenge the perceived
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
immutability of the social order. As a result of their gender identities and non-conformity, they are discriminated against and ostracised from society.
Photo courtesy of Jana Villayzan
In Latin America and the Caribbean there is little acceptance of gender diversity, which is reflected in the high rates of stigma and discrimination that transgender women (used here as an umbrella term for transvestites, transgenders, and transsexuals) suffer on a daily basis. Despite calls to protect the human rights of transgender women from international bodies, such as the Organization of American States and the United Nations, most nations in this region do not promote such legislation, perhaps because of the political influence of some religious fundamentalist groups. Many studies across the region highlight the adverse social, political, and economic situation in which transgender women live. They are frequently denied access to work and education, and they are often
1
Perspectives
health, and do not include primary health-care services. Unsurprisingly, these interventions have not achieved the expected results, because they do not address the social exclusion that leads to high-risk behaviours. Therefore, policy makers should promote a broad range of policies that address social, economic, and political inclusion to not only protect the human rights of transgender people, but also to improve access to health care.
This social and legal marginalisation directly affects public health efforts, since up to 70% of transgender women in Peru depend on sex work for economic survival. This puts them in a situation of risk for contracting HIV and other sexually transmitted infections, illustrated by the high HIV prevalence of about 20–40% in this population in the region. However, public health efforts for transgender women in many countries focus only on sexual
Jana Villayzan Jana Villayzan is the Executive Director of the National Network for the Rights of transvestites, transgenders and transsexuals movement of Peru, known as RED TRANS PERU. She received her Masters in Public Health, with a major in Gender, Sexuality and Sexual Health, from the Universidad Peruana Cayetano Heredia. With 16 years of work on empowerment and skills development of transwomen leaders, she has been an advocate for a more equitable environment for trans women in Peru and Latin America.
Lesotho: standing up for transgender health and rights Living proudly as a transgender man in the small sub-Saharan country of Lesotho has come at a serious price. My public activism on issues of sexual orientation and gender identity and expression makes me vulnerable to threats to my personal safety. The widespread instances of “corrective” rape against transgender men and lesbian women mean that I must constantly be careful and vigilant in every kind of public space, from entertainment venues to walks home from work. Gender prejudice is a norm in Lesotho, so in
addition to these fears and the work I do as Director of the People’s Matrix Association (Matrix Support Group), gaining my family’s acceptance is its own burden. Beyond fears for discrimination and violence in public and even private settings, there are countrywide infrastructure challenges, such as poor internet connection and capacity stressors. Like many such organisations, resources are limited at the People’s Matrix Association and there are few opportunities for professional development, which
makes planning and implementation work extremely challenging. All of which seriously affects my professional and personal life, as I sometimes must sacrifice my personal resources just to keep the organisation running. The late hours this work often requires further endangers my personal safety, not to mention affecting my relationship with partners and friends. There is hope, however, and that is that I am not alone in this struggle. In the past 6 months, I have gained a mentor guiding me in the organisational development process, and strengthening my self-esteem as I work toward achieving dignity for all transgender people in Lesotho.
Photo courtesy of Tampose Mothopeng/photo Meri Mpho Hyöky
Tampose Mothopeng
2
Tampose Mothopeng is the Director of the People’s Matrix Association (Matrix Support Group) in Lesotho, an organisation specialising in civic education, health care, human rights, policy advocacy, research, women’s issues, and youth empowerment. During his time at the People’s Matrix Association (Matrix Support Group), he has organised strategies to meet the health needs of transgender and non-conforming individuals and responded directly to the health needs of gay and bisexual men through newly developed programmes. Additionally, he has participated in programmes to address LGBT and gender-based violence and develop LGBT youth art and advocacy networks.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
Perspectives
South Africa: access to gender-affirming health care
Photo courtesy of L Leigh Ann van der Merwe
My own reality as a transgender woman of colour from rural South Africa is what brought me to the fight for justice for other transgender women in South Africa and beyond. In South Africa, the legacy of colonialism, institutionalised inequality, and apartheid shaped the current reality of people of colour, especially for transgender people of colour. All of these intersecting
factors lead to a complex array of challenges I can only begin to address. The legal context makes life difficult. South African law allows for transgender people to change names and gender markers, but the law is implemented inconsistently. When legal documents do not match the identities of transgender persons, it presents a huge challenge for accessing health and other social services. The health context also affects our lives. There are only two facilities in South Africa where gender-affirming surgeries are done, and both have a shocking waiting list of many years. Often when transgender people do not get to be their authentic and true selves, the mental–physical disconnect factors into transgender people not “taking care” of themselves. This manifests in high-risk behaviours like sex work that increase HIV risk. The social context also presents challenges. A Transilience study on violence against transgender women in South Africa showed that 85% of trans women have experienced violence in one way or the other,
and the picture is worse for trans women of colour. Another problem for many communities of colour is ritual circumcision. This practice is fraught with gendered implications, since the ritual represents becoming a man, which directly conflicts with the feminine identities of transgender women. However, to reject this tradition often means rejection from families, financial ruin, homelessness, and health risks.
L Leigh Ann van der Merwe L Leigh Ann van der Merwe is the Coordinator and Founder of S.H.E (Social, Health and Empowerment Feminist Collective of Transgender And Intersex Women of Africa). Leigh Ann was born in Ugie, Eastern Cape of South Africa. Leigh Ann has extensive experience in research pertaining to public health, sexual and reproductive health, and feminism. She holds a certificate in Community Journalism from the University of South Africa and is currently enrolled in the postgraduate programme in Public Health at the University of the Western Cape. Over the past 8 years, Leigh Ann has held positions with several local and international agencies and non-governmental organisations, and has presented and consulted extensively on transgender women’s issues. She was also a fellow in the Open Society/Austrian American Foundation/Transgender Centre of Excellence programme.
Australia: lessons from progress to date Almost a decade ago, I transitioned from living as a lesbian to living as a transgender man in Australia. Though I was excited for physical changes, I was completely shocked to discover that seemingly overnight I lost many of the legal rights and protections recognised to me before beginning my gender transition. I found that I now lacked legal protections from discrimination and the legal validation of my gender identity. To make matters worse, the medical care I required to transition was not available through the public health system. Thankfully, some 10 years later, much has changed. Australia’s
national anti-discrimination laws now do afford protection to transgender and intersex Australians. We can obtain many government documents in our lived gender, and regulations that govern amendments to birth certificates are gradually improving. From my perspective, this fairly rapid improvement can be attributed to three key ingredients. First, visibility. More and more transgender people in Australia have courageously become highly public about their lives, experiences, and identities. Now the community knows we exist, and is beginning to understand our issues.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
Second, there has been a multiplestrategy approach. Be it achieving victories in the courts, changing policy within political parties, or lobbying parliamentarians with the needs of transgender citizens, we’ve tried it! And trying every different angle has seen results. Third, collaboration. Rather than only shouting from the outside, we’ve partnered with our gay, lesbian, and intersex colleagues, and with government itself, to bring about change. This approach has been highly effective. Of course, there is more to be done. The rate of mental illness within the transgender community is of 3
Perspectives
and our organisations need funding. But given the success that we’ve had, and that we now know what works in Australia, I am confident that the future looks bright.
Aram Hosie
Photo courtesy of Aram Hosie
Aram Hosie holds a BSc in Occupational Therapy from Curtin University of Technology and a MA in Politics and Policy from Deakin University. After initially beginning his career as a mental health provider, Aram has gone on to hold a variety of senior health and social policy roles within government and civil society. Aram currently serves as the Executive Manager, Public Affairs for cohealth, and is a Board Member for the Victorian AIDS Council. Aram is a well known advocate with a proven track record as an effective human rights advocate for LGBTI rights, and the global HIV response.
serious concern. Anti-discrimination and gender recognition laws still
need further improvement. We need better access to medical treatment
USA: at the margin of gender and race
Photo courtesy of Cecilia Chung
As we turn our attention on institutionalised violence against communities of colour in the USA, it is heartening to see the emergence of a solidarity demanding justice for Michael Brown, Eric Garner, and Tamir Rice. Yet, I cannot help but wonder why there is not the same outrage when violence has robbed the lives of Black trans women. To me, that seems like an unfinished dialogue.
4
National Coalitions of AntiViolence Projects reported that trans women of colour accounted for 67% of all hate-motivated homicides of LGBT people in 2013 in the USA. According to the US National Transgender Discrimination Survey, 41% of black trans people have been incarcerated as a result of anti-trans bias, compared with 4% of white respondents. In fact, the survey showed that 47% of black trans people have experienced incarceration in the USA. Moreover, 38% of incarcerated black trans women were sexually assaulted in jail, according to the survey. Sadly, this has been an ongoing crisis in this nation, despite the many legislative advances in trans rights. The National Institutes of Health reported high rates of HIV among black trans women and trans Latinas in one study—56% of black trans women were HIV positive and 16% of trans Latinas. These statistics are the lived realities of my black and Latina trans sisters and I hope you would find them as heart-breaking as I did.
Perhaps as we continue to feel the outrage of current events, participate in the protests, and contribute to the social media trends on #BlackLivesMatter and #SayHerName, we can invite a deeper dialogue of how race intersects with gender, gender identity, and violence. And rather than just grieving the dead, let us build a global movement that transforms hearts and minds so that all trans people, especially Black and Brown trans women, can thrive and enjoy a life free from fear.
Cecilia Chung Cecilia Chung is the Senior Strategist of the Transgender Law Center in Oakland, CA, USA, and is nationally recognised as an advocate for human rights, social justice, health equity, and LGBT equality. She is the former Chair of the San Francisco Human Rights Commission and is currently serving on the San Francisco Health Commission. Cecilia has been working tirelessly on the local, national, and international levels to improve access to treatment for transgender people and people living with HIV, and to erase stigma and discrimination through education, policy, advocacy, and visibility. Cecilia founded Positively Trans in 2015 to develop and support trans leaders living with HIV across the USA.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
Transgender community voices: a participatory population perspective Understanding the global health burden and needs of transgender communities necessitates meaningful engagement and involvement of transgender people. Against the backdrop of widespread social and economic exclusion facing people of diverse gender identities and experiences, community empowerment is essential for clinical services, public health programmes, and human rights efforts that seek to design and implement effective services and population-level interventions to improve the health and wellbeing of transgender people. A participatory population perspective necessitates working with—and not through—local, national, and global transgenderled organisations in the conduct of research and evaluation, delivery
of gender-affirmative clinical care, education and training, and policy and advocacy. From this perspective, we have invited transgender leaders to contribute narratives of their experiences in their local context. These transgender voices bring to life the social contexts, epidemiological data, and identified health-care needs presented across the Lancet Series papers on transgender health; they are especially meant to accompany Sari Reisner and colleagues’ review of the global health burden and needs—a paper on which most of the authors are themselves transgender men and women. The voices narratives are not meant to be, nor could they be, representative of the entire global transgender community given the
heterogeneity of transgender people worldwide. However, these voices are powerful examples of the lived knowledge and personal experiences of transgender people.
Published Online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)00683-8, http://dx.doi.org/10.1016/ S0140-6736(16)00682-6, and http://dx.doi.org/10.1016/ S0140-6736(16)00684-X
*Sari Reisner, JoAnne Keatley, Stefan Baral Division of General Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA (SR); Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA (SR); The Fenway Institute, Fenway Health, Boston, MA, USA (SR); Center of Excellence for Transgender Health, University of California San Francisco, San Francisco, California, USA (JK); and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (SB) [email protected]
Peru: access to health and adverse social context expelled from their homes because of their desire to live differently from their assigned sex. Due to rigid patriarchal norms, transgender women challenge the perceived
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
immutability of the social order. As a result of their gender identities and non-conformity, they are discriminated against and ostracised from society.
Photo courtesy of Jana Villayzan
In Latin America and the Caribbean there is little acceptance of gender diversity, which is reflected in the high rates of stigma and discrimination that transgender women (used here as an umbrella term for transvestites, transgenders, and transsexuals) suffer on a daily basis. Despite calls to protect the human rights of transgender women from international bodies, such as the Organization of American States and the United Nations, most nations in this region do not promote such legislation, perhaps because of the political influence of some religious fundamentalist groups. Many studies across the region highlight the adverse social, political, and economic situation in which transgender women live. They are frequently denied access to work and education, and they are often
1
Perspectives
health, and do not include primary health-care services. Unsurprisingly, these interventions have not achieved the expected results, because they do not address the social exclusion that leads to high-risk behaviours. Therefore, policy makers should promote a broad range of policies that address social, economic, and political inclusion to not only protect the human rights of transgender people, but also to improve access to health care.
This social and legal marginalisation directly affects public health efforts, since up to 70% of transgender women in Peru depend on sex work for economic survival. This puts them in a situation of risk for contracting HIV and other sexually transmitted infections, illustrated by the high HIV prevalence of about 20–40% in this population in the region. However, public health efforts for transgender women in many countries focus only on sexual
Jana Villayzan Jana Villayzan is the Executive Director of the National Network for the Rights of transvestites, transgenders and transsexuals movement of Peru, known as RED TRANS PERU. She received her Masters in Public Health, with a major in Gender, Sexuality and Sexual Health, from the Universidad Peruana Cayetano Heredia. With 16 years of work on empowerment and skills development of transwomen leaders, she has been an advocate for a more equitable environment for trans women in Peru and Latin America.
Lesotho: standing up for transgender health and rights Living proudly as a transgender man in the small sub-Saharan country of Lesotho has come at a serious price. My public activism on issues of sexual orientation and gender identity and expression makes me vulnerable to threats to my personal safety. The widespread instances of “corrective” rape against transgender men and lesbian women mean that I must constantly be careful and vigilant in every kind of public space, from entertainment venues to walks home from work. Gender prejudice is a norm in Lesotho, so in
addition to these fears and the work I do as Director of the People’s Matrix Association (Matrix Support Group), gaining my family’s acceptance is its own burden. Beyond fears for discrimination and violence in public and even private settings, there are countrywide infrastructure challenges, such as poor internet connection and capacity stressors. Like many such organisations, resources are limited at the People’s Matrix Association and there are few opportunities for professional development, which
makes planning and implementation work extremely challenging. All of which seriously affects my professional and personal life, as I sometimes must sacrifice my personal resources just to keep the organisation running. The late hours this work often requires further endangers my personal safety, not to mention affecting my relationship with partners and friends. There is hope, however, and that is that I am not alone in this struggle. In the past 6 months, I have gained a mentor guiding me in the organisational development process, and strengthening my self-esteem as I work toward achieving dignity for all transgender people in Lesotho.
Photo courtesy of Tampose Mothopeng/photo Meri Mpho Hyöky
Tampose Mothopeng
2
Tampose Mothopeng is the Director of the People’s Matrix Association (Matrix Support Group) in Lesotho, an organisation specialising in civic education, health care, human rights, policy advocacy, research, women’s issues, and youth empowerment. During his time at the People’s Matrix Association (Matrix Support Group), he has organised strategies to meet the health needs of transgender and non-conforming individuals and responded directly to the health needs of gay and bisexual men through newly developed programmes. Additionally, he has participated in programmes to address LGBT and gender-based violence and develop LGBT youth art and advocacy networks.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
Perspectives
South Africa: access to gender-affirming health care
Photo courtesy of L Leigh Ann van der Merwe
My own reality as a transgender woman of colour from rural South Africa is what brought me to the fight for justice for other transgender women in South Africa and beyond. In South Africa, the legacy of colonialism, institutionalised inequality, and apartheid shaped the current reality of people of colour, especially for transgender people of colour. All of these intersecting
factors lead to a complex array of challenges I can only begin to address. The legal context makes life difficult. South African law allows for transgender people to change names and gender markers, but the law is implemented inconsistently. When legal documents do not match the identities of transgender persons, it presents a huge challenge for accessing health and other social services. The health context also affects our lives. There are only two facilities in South Africa where gender-affirming surgeries are done, and both have a shocking waiting list of many years. Often when transgender people do not get to be their authentic and true selves, the mental–physical disconnect factors into transgender people not “taking care” of themselves. This manifests in high-risk behaviours like sex work that increase HIV risk. The social context also presents challenges. A Transilience study on violence against transgender women in South Africa showed that 85% of trans women have experienced violence in one way or the other,
and the picture is worse for trans women of colour. Another problem for many communities of colour is ritual circumcision. This practice is fraught with gendered implications, since the ritual represents becoming a man, which directly conflicts with the feminine identities of transgender women. However, to reject this tradition often means rejection from families, financial ruin, homelessness, and health risks.
L Leigh Ann van der Merwe L Leigh Ann van der Merwe is the Coordinator and Founder of S.H.E (Social, Health and Empowerment Feminist Collective of Transgender And Intersex Women of Africa). Leigh Ann was born in Ugie, Eastern Cape of South Africa. Leigh Ann has extensive experience in research pertaining to public health, sexual and reproductive health, and feminism. She holds a certificate in Community Journalism from the University of South Africa and is currently enrolled in the postgraduate programme in Public Health at the University of the Western Cape. Over the past 8 years, Leigh Ann has held positions with several local and international agencies and non-governmental organisations, and has presented and consulted extensively on transgender women’s issues. She was also a fellow in the Open Society/Austrian American Foundation/Transgender Centre of Excellence programme.
Australia: lessons from progress to date Almost a decade ago, I transitioned from living as a lesbian to living as a transgender man in Australia. Though I was excited for physical changes, I was completely shocked to discover that seemingly overnight I lost many of the legal rights and protections recognised to me before beginning my gender transition. I found that I now lacked legal protections from discrimination and the legal validation of my gender identity. To make matters worse, the medical care I required to transition was not available through the public health system. Thankfully, some 10 years later, much has changed. Australia’s
national anti-discrimination laws now do afford protection to transgender and intersex Australians. We can obtain many government documents in our lived gender, and regulations that govern amendments to birth certificates are gradually improving. From my perspective, this fairly rapid improvement can be attributed to three key ingredients. First, visibility. More and more transgender people in Australia have courageously become highly public about their lives, experiences, and identities. Now the community knows we exist, and is beginning to understand our issues.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7
Second, there has been a multiplestrategy approach. Be it achieving victories in the courts, changing policy within political parties, or lobbying parliamentarians with the needs of transgender citizens, we’ve tried it! And trying every different angle has seen results. Third, collaboration. Rather than only shouting from the outside, we’ve partnered with our gay, lesbian, and intersex colleagues, and with government itself, to bring about change. This approach has been highly effective. Of course, there is more to be done. The rate of mental illness within the transgender community is of 3
Perspectives
and our organisations need funding. But given the success that we’ve had, and that we now know what works in Australia, I am confident that the future looks bright.
Aram Hosie
Photo courtesy of Aram Hosie
Aram Hosie holds a BSc in Occupational Therapy from Curtin University of Technology and a MA in Politics and Policy from Deakin University. After initially beginning his career as a mental health provider, Aram has gone on to hold a variety of senior health and social policy roles within government and civil society. Aram currently serves as the Executive Manager, Public Affairs for cohealth, and is a Board Member for the Victorian AIDS Council. Aram is a well known advocate with a proven track record as an effective human rights advocate for LGBTI rights, and the global HIV response.
serious concern. Anti-discrimination and gender recognition laws still
need further improvement. We need better access to medical treatment
USA: at the margin of gender and race
Photo courtesy of Cecilia Chung
As we turn our attention on institutionalised violence against communities of colour in the USA, it is heartening to see the emergence of a solidarity demanding justice for Michael Brown, Eric Garner, and Tamir Rice. Yet, I cannot help but wonder why there is not the same outrage when violence has robbed the lives of Black trans women. To me, that seems like an unfinished dialogue.
4
National Coalitions of AntiViolence Projects reported that trans women of colour accounted for 67% of all hate-motivated homicides of LGBT people in 2013 in the USA. According to the US National Transgender Discrimination Survey, 41% of black trans people have been incarcerated as a result of anti-trans bias, compared with 4% of white respondents. In fact, the survey showed that 47% of black trans people have experienced incarceration in the USA. Moreover, 38% of incarcerated black trans women were sexually assaulted in jail, according to the survey. Sadly, this has been an ongoing crisis in this nation, despite the many legislative advances in trans rights. The National Institutes of Health reported high rates of HIV among black trans women and trans Latinas in one study—56% of black trans women were HIV positive and 16% of trans Latinas. These statistics are the lived realities of my black and Latina trans sisters and I hope you would find them as heart-breaking as I did.
Perhaps as we continue to feel the outrage of current events, participate in the protests, and contribute to the social media trends on #BlackLivesMatter and #SayHerName, we can invite a deeper dialogue of how race intersects with gender, gender identity, and violence. And rather than just grieving the dead, let us build a global movement that transforms hearts and minds so that all trans people, especially Black and Brown trans women, can thrive and enjoy a life free from fear.
Cecilia Chung Cecilia Chung is the Senior Strategist of the Transgender Law Center in Oakland, CA, USA, and is nationally recognised as an advocate for human rights, social justice, health equity, and LGBT equality. She is the former Chair of the San Francisco Human Rights Commission and is currently serving on the San Francisco Health Commission. Cecilia has been working tirelessly on the local, national, and international levels to improve access to treatment for transgender people and people living with HIV, and to erase stigma and discrimination through education, policy, advocacy, and visibility. Cecilia founded Positively Trans in 2015 to develop and support trans leaders living with HIV across the USA.
www.thelancet.com Published online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30709-7